Do you struggle with bloating? Perhaps you also suffer other digestive symptoms, like constipation, diarrhoea, flatulence and nausea? If so, you’re not alone. Of the patients I see in clinical practice, I would estimate more than half struggle with bloating or digestive disturbance in one way or another, however many simply learn to put up with the discomfort! This is a sad reality, as persistent bloating is NOT NORMAL and means there is some form of underlying disturbance that needs to be addressed. Many of these patients come to me to address other issues (such as thyroid or hormonal disorders), but addressing digestive issues like bloating and constipation is integral to any holistic treatment strategy, as so much of our health is affected by the health of our digestive system.
For those with a long history of digestive issues, many have already tried various remedies and diets, often to minimal success. They may have gone gluten or dairy free, and they’ve often tried things like apple cider vinegar, probiotics and digestive enzymes as well. Whilst these approaches can certainly be helpful, they don’t necessarily identify or address the underlying CAUSE of the bloating, meaning once they are stopped, symptoms often return. As a naturopath, my aim is to get to the bottom of the condition and work out what is going on, so I can prescribe an appropriate treatment or dietary recommendations that directly address the cause of dysfunction, and not just the symptoms. In this article today, I’m going to explore some of the potential causes of bloating that we commonly see in clinical practice:
Constipation is perhaps the most common cause of bloating we see at our clinic. When constipated, digestive matter is not being cleared from the colon as regularly and effectively as it should be, leading to feelings of fullness and discomfort. The longer the stool sits in the colon, the more time bacteria have to ferment what’s there, leading to gas production. All this bacterial fermentation and gas production leads to bloating and in some cases, flatulence as well.
Interestingly, many patients don’t even realise they are constipated, because they have been that way for so long. You can still be pooing daily and be suffering constipation, as you may not be fully emptying your bowels with each bowel movement. In addition to bloating, some common signs of constipation include:
Not passing a bowel motion every day
Stools that are hard, pebbly or appear somewhat ‘dried up’
Stools that feel incomplete (e.g. like you could go again)
Stools that are painful or difficult to pass
If I suspect constipation to be the cause of my patient’s bloating, the first thing I do is put them on a healthy eating approach designed specifically to get them passing a full, easy and complete bowel motion at least once daily. I also address factors like fluid consumption and exercise, and if need be, rule out possible pathological causes of constipation, such as underactive thyroid function. In some cases, I may use specific, evidence-based prebiotics designed to improve gastrointestinal motility and transit time, to improve daily clearance, however in general, constipation typically resolves quickly and easily once key dietary adjustments are made.
2. Dysbiosis (Parasites, SIBO and More)
Another potential cause of bloating is dysbiosis - this refers to having an imbalance in the types or amounts of bacteria and other micro-organisms present in the digestive tract. Dysbiosis presents in many forms, such as having parasites, small intestinal bacterial overgrowth (SIBO) and/or having an overgrowth of certain micro-organisms in the large intestine. Bacteria in our gut ferment the foods we eat, and this fermentation process produces various gases. If there is an imbalance in the type of bacteria present however, bloating can occur due to excess production of gases such as hydrogen peroxide and methane. Certain types of bacterial overgrowth in the digestive tract can also lead to constipation, which further fuels the bloating-constipation cycle.
Addressing dysbiosis requires appropriate testing to identify the specific nature of the imbalance. This might involve a stool test to assess for parasites, or to understand the types of bacteria that are present, and in what proportions. Once the specific issue has been identified, appropriate measures can be put in place to correct the imbalance and promote the growth of a healthy gastrointestinal ecosystem.
3. Autoimmune Disease
Various autoimmune diseases have been associated with bloating, and these include coeliac disease, Crohn’s disease and autoimmune thyroid disease. All of these conditions affect the digestive tract in various ways, which can predispose the individual to bloating and abdominal discomfort. Interestingly, certain autoimmune diseases often co-occur, so it is not uncommon to be treating an individual with both coeliac disease and Hashimoto’s disease. There has been some suggestion that gastroparesis (another condition associated with bloating) may have an underlying autoimmune component as well, however this has yet to be elucidated.
If an autoimmune disease is suspected on the basis of symptoms, medical history and other clinical findings, then referral must be made for appropriate investigations to be undertaken. In the case of coeliac disease or autoimmune thyroid disease, the first line investigation is often a simple blood test, followed by follow-up investigations where warranted. In the cause of bloating associated with an autoimmune thyroid disease, correcting thyroid function is essential to improving digestive symptoms. For coeliac disease, removing all forms of gluten from the diet is essential, to enable the gut to heal. Naturopathically, we may also prescribe specific nutrients and herbal medicines designed to reduce inflammation in the gut lining and promote healing of the gastrointestinal mucosa and villi, with nutrients such as zinc carnosine, vitamin A, quercetin and slippery elm.
4. Food Intolerances
Food intolerances are commonly associated with bloating, and in many cases, patients have already identified specific foods that trigger their symptoms. Common causes we see in clinical practice include sensitivities to foods like dairy (due to lactose intolerance), dried fruits (often due to sulphite sensitivity), alcohol, wheat, sugar alcohols (like xylitol and sorbitol) and histamine-containing foods (such as aged cheese and cured meats).
Other patients react to certain types of short-chain carbohydrates known as FODMAPs. FODMAPs stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols. Those with a FODMAP sensitivity are particularly susceptible to bacterial fermentation of these types of carbohydrates, resulting in gas production and bloating. In some cases, diarrhoea also occurs, as these carbohydrates have osmotic properties, meaning they draw water into the bowel. Whilst low FODMAP diets deserve an article of their own, It’s important to note that whilst they can be helpful to alleviate symptoms (especially in cases of diagnosed IBS), a low FODMAP diet is only recommended in certain circumstances and as a short-term approach.
Typically, the best way to identify a food intolerance is to eliminate suspected foods from the diet for a number of weeks (until symptoms have fully resolved) and then gradually reintroduce them one by one, and assess for a reaction. Keeping a diet-symptom diary during this time can also be beneficial.
Endometriosis is a condition that affects 5-10% of menstruating women in Australia, although many are undiagnosed so some estimates are even higher. Endometriosis occurs when the tissue that normally lines the uterus grows in other parts of the body, such as the bowel or abdominal cavity. Common symptoms include painful and heavy periods, pain during intercourse, pain with bowel movements/urination and infertility. One lesser known symptom of endometriosis however is ‘endobelly’ - a colloquial term used to refer to the bloating many women with endometriosis experience. This bloating is typically worse in the week or so leading up to the woman’s period, and often resolves within a day or two of the onset of menstruation. Bloating associated with endometriosis can be severe and highly uncomfortable, so if you experience those other symptoms listed above (such as very painful and heavy periods), talking to your healthcare practitioner about being investigated for endometriosis may be worthwhile.
Note: Bloating pre-period is certainly not restricted to women with endometriosis alone. Many women without endometriosis also experience bloating before or during their period, and sometimes this co-occurs with symptoms like constipation and diarrhoea as well. If you do experience changes in bowel habits or digestive function relating to your menstrual cycle, working with a naturopath or nutritionist can be a great way to help address those symptoms.
There are certainly many other potential causes of bloating that need to be ruled out if addressing the factors above fail to alleviate your symptoms. In all cases, it is advisable to work with a qualified healthcare practitioner who can assess your presenting symptoms and family history, and where necessary, recommend appropriate investigations to be conducted in a systematic and evidence-informed manner. If you’re booked in to see a naturopath, doctor or specialist in the upcoming weeks, keeping track of your daily symptoms can provide hugely valuable information for your healthcare provider. Details you might like to note include the type, nature and timing of the symptom (e.g. bloating and gas, 30 minutes after dinner), as well as any foods consumed, and if there was anything you did that improved your symptoms.